Renal cell carcinoma

1. Renal cell carcinoma
Mohammed AlHinai

2. • 60 yrs old male patient is referred to urology OPD with history of blood in
urine on and off for the last 6 months. He has passed long ribbon like clot on
two occasions associated with right flank pain radiated from loin to groin. He
has loss of appetite and weight loss. Previous investigation showed
hypercalcemia.
Differential diagnosis

3. • As the patient present with hematuria and ribbon like
clots which indicate bleeding above the urinary bladder.
He had also flank pain with weight loss.
Our patient
Think about

4. Renal tumors
Primary tumors :
Secondary tumors :
• As metastasis from :
- Lung cancer.
- Breast cancer.
- Stomach cancer.
• Leukemia.
• Lymphoma
Benign tumors :
• Adenoma (most
common).
• Papilloma
• fibroma
• lipoma
• haemangioma
• oncocytoma.
Malignant tumors :
• Parenchymal (90%):
- Renal cell carcinoma (most
common among adult 70%).
- Wilm’s tumor or nephroblastoma
(most common in pediatric 10%).
- leiomyosarcoma,
haemangiosarcoma (5%)
• Urothelial from collecting
system as calyx and ureteric
pelvis (10%) :
- Transitional cell carcinoma (TCC).
- Squamous cell carcinoma (SCC).

5. Renal tumor :
• originate within the renal cortex, are responsible for 80 to 85 percent
of all primary renal neoplasms.
Risk factors :
Environmental factors:
• Smoking
• Occupational exposure
to toxic compounds,
such as cadmium,
asbestos, and petroleum
by-products.
Genetic :
• increased risk is most
pronounced in first
degree relatives with a
tumor, onset before the
age of 40, and bilateral
or multifocal disease.
Miscellaneous factors:
• Hypertension
• Obesity
• Acquired cystic disease of
the kidney.
• Cytotoxic chemotherapy.
• Chronic hepatitis C
infection.
• Sickle cell disease
• Kidney stones

6. Types of RCC according to pathology
• Clear cell (75%).
• Papillary (10%)
• Chromophobe (5)
• Oncocytic (3)
• Collecting duct (Bellini's duct) (very rare)

7. Clinical manifestation :
Local manifestation :
• Many patient are asymptomatic until the disease is locally advanced.
• Classic triad of RCC include :
- Painless profuse Hematuria with ribbon like clot formation.
- Abdominal or flank mass which firm or hard, homogenous and non-tender.
- Flank pain with dull aching or colicky in nature.
• Constitutional symptoms:
- Weight loss and cachexia
- Fever and night sweating.
• Paraneoplastic symptoms :
- Anemia.
- Hypercalcemia as Overproduction of parathyroid hormone-related protein (PTHrP).
- Erthyrocytosis as constitutive production of erythropoietin.
- Thrombocytosis as related to IL-6 production by the tumor.
- Hepatic dysfunction result from tumor production of cytokines, such as granulocyte-
macrophage colony-stimulating factor (GM-CSF) and possibly interleukin (IL)-6.

8. Local advanced and Metastatic manifestation :
• Severe bleeding by renal pelvis invasion.
• Scrotal varicoceles usually of left side as obstructed the gonadal vein.
• Inferior vena cava involvement cause lower extremity edema, ascites,
hepatic dysfunction and pulmonary emboli.
• Distant Metastasis usually by blood vessel involve lung, lymph nodes,
bone, liver and brain.

9. Approach to patient with
RCC

10.  Full history and clinical examination.
 Laboratory test include :
• Urinalysis :
- RBC present in urine dipstick.
- Normally or distorted shaped RBC in microscopic.
- Urine culture to rule out UTI.
• RFT to assess the function
• Tumor markers.
• Other laboratory test include CBC, coagulation
profile and LFT.
 Imaging studies :
• KUB x-ray to exclude other causes.
• abdomen US may show mass or cyst and renal
stones
• 60 yrs old male patient is referred to urology OPD with history of blood in
urine on and off for the last 6 months. He has passed long ribbon like clot on
two occasions associated with right flank pain radiated from loin to groin. He
has loss of appetite and weight loss. Previous investigation showed
hypercalcemia.
Hypoechoic solid mass in cortex
of kidney

11.  CT urography (diagnostic):
• Use to assess the mass by features of :
- Thickened irregular wall or septa mass.
- Enhancement after contrast injection.
• Assess any local advanced of malignancy.
 MRI abdomen :
• Use if CT urography contraindicated or
inconclusive result.
• More accurate with same features and
assess extent of involvement of the
collecting system and/or inferior vena cava.
• Dynamic contrast enhanced MRI useful for
determining histology as clear cell carcinoma
showing greater signal intensity change in
the corticomedullary and nephrographic
phase than either papillary or chromophobe
carcinomas

12.  For staging and metastatic workup :
• CT scan or MRI.
• Chest x-ray.
• Bone survey
• Brain scan
• PET scanning
 Percutaneous biopsy :
• Not indicated for every patient as imaging CT or MRI diagnostic for
RCC.
• Biopsy needed :
- In case of high index of suspicion for a metastatic lesion to the
kidney, lymphoma, or a focal kidney infection.
- in patients who are not surgical candidates prior to initiating
appropriate medical treatment.
• Biopsy of metastatic lesion is often preferable.

13. Staging system

14. Management
Depend on the staging system and patient comorbidities if fit for surgery
 RCC without locally advance or metastasis (stage I, II, III):
Radical nephrectomy :
• Standard cure.
New modalities:
• Use cryoablation and
radio frequency
ablation.
• Use for patient not
candidate for surgical
management as
comorbidities.
Partial nephrectomy or
nephron sparing surgery:
• Indication :
- Patient with solitary kidney.
- Malfunction of both kidney.
- Tumor <4cm.
- unilateral RCC and the
contralateral kidney is at risk
for dysfunction in the future.
 Adjuvant therapy
• To reduce the risk of recurrence and increased survival rate by given :
- Immunotherapy including interferon-alfa, interleukin-2, and autologous
tumor vaccines.

15.  Surveillance after resection
• Careful surveillance following surgical resection is important to permit
early diagnosis of relapse when the tumor burden is limited.

16.  RCC with locally advance or metastasis stage IV :
Locally advanced :
• Radical or partial nephrectomy
if possible.
• Remove of extension of tumor.
• Continue with radiotherapy.
Metastatic tumor :
• Palliative nephrectomy if possible.
• Radiotherapy.
• Biologic response modifiers as :
- interferon-a.
- Interleukin-2.
 Surveillance and continue palliative care

17. Prognosis
• Depend on stage of tumor and treatment response